Management of Anti-Seizure Medications during Pregnancy: Advancements in The Past Decade

Development, in vitro and ex vivo characterization of lamotrigine-loaded bovine serum albumin nanoparticles using QbD approach

The present study aimed to prepare and optimize lamotrigine-loaded bovine serum albumin nanoparticles (LAM-NP) using the Quality by Design (QbD) approach and to investigate both the in vitro and ex vivo effects of different cross-linking agents glutaraldehyde (GLUT), glucose (GLUC) and 1-(3-dimethylaminutesopropyl)-3-ethylcarbodiimide hydrochloride (EDC) on intranasal applicability. Cross-linked LAM-NP from EDC (NP-EDC-1) showed the lowest Z-average value (163.7 ± 1.9 nm) and drug encapsulation efficacy (EE%) of 97.31 ± 0.17%. The drug release of GLUC cross-linked LAM-NP (NP-GLUC-9), glutaraldehyde cross-linked LAM-NP (NP-GLUT-2), and NP-EDC-1 at blood circulation conditions was higher than the initial LAM. The results of the blood-brain barrier parallel artificial membrane permeability assay (BBB-PAMPA) showed an increase in the permeability of LAM through the BBB with NP-GLUC-9 and an increase in flux with all selected formulations. The ex vivo study showed that LAM diffusion from the selected formulations through the human nasal mucosa was higher than in case of initial LAM. The cytotoxicity study indicated that BSA-NP reduced LAM toxicity, and GLUC 9 mM and EDC 1 mg could be alternative cross-linking agents to avoid GLUT 2% v/v toxicity. Furthermore, permeability through Caco-2 cells showed that nasal epithelial transport/absorption of LAM was improved by using BSA-NPs. The use of BSA-NP may be a promising approach to enhance the solubility, permeability through BBB and decrease the frequency of dosing and adverse effects of LAM.

Review of pharmacology of medications during pregnancy

Ninety percent of pregnant patients take at least one medication during pregnancy. Physiological changes during pregnancy can alter drug exposure. Understanding basic physiological principles including absorption, distribution, metabolism and excretion can guide medication management during pregnancy. While physiologic changes related to medications used to treat hypothyroidism, depression and epilepsy are highlighted in this article, the principles of pharmacokinetic changes during pregnancy can be applied to other medical conditions where less data may exist. Given the complexity of pharmacology, physiological changes of pregnancy, and nuances of managing medical conditions, a team approach to managing medications in pregnancy is recommended. Comprehensive care including general and specialized physicians, pharmacists, genetic counselors and more can help provide the most appropriate care to this multifaceted patient population.

Implementing Guidelines and Measures in Epilepsy Care

ABSTRACT

People with epilepsy must receive up-to-date, high-quality care that aligns with current understanding of basic disease mechanisms, improved diagnostic testing, and evolving medical and surgical treatments. Varying progress has been made in identifying, measuring, and mitigating epilepsy care gaps. Epilepsy guidelines and quality measures should be developed using rigorous processes informed by systematic reviews of best evidence in conjunction with prioritization of need. Epilepsy measures help operationalize guidelines and practice parameters. Most epilepsy quality indicators are process-based metrics defined by delivering care to the patient. Systematic and reliable tracking and documentation of seizure frequency using consistent language is required as a patient-reported outcome within individuals over time and across populations. Emerging literature has demonstrated gaps in epilepsy care, perhaps highlighting limitations in the dissemination and implementation of guidelines and quality measures in clinical practice. Quality improvement methods applied to clinical data registries and learning health systems may afford new opportunities to iteratively, collaboratively, and feasibly disseminate guidelines and quality measures, measure epilepsy care quality, allow for the testing of interventions to mitigate identified care gaps, and, ultimately, improve care for patients with epilepsy.

Prediction of lacosamide concentrations to support dose optimization during pregnancy

OBJECTIVE

We aimed to quantify and predict lacosamide exposure during pregnancy by developing a pregnancy physiologically-based pharmacokinetic model, allowing the prediction of potential dose increases to support maintaining a patient's preconception lacosamide concentrations.

METHODS

Models for nonpregnant adults and pregnant female patients were constructed using physiochemical and pharmacological parameters identified from literature review. Evaluation of plasma concentration data from human males was digitized from the literature. Concentration data in nonpregnant and pregnant human females were available from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, a longitudinal observational study which followed 11 nonpregnant and 16 pregnant women receiving lacosamide. Evaluation was conducted qualitatively with visual overlay (>80% of observed concentrations within 90% confidence interval) and quantitatively with average fold error and absolute average fold error (0.8-1.25 ratio acceptance criteria). Simulations of intensively-sampled dosing regimens at steady-state dosing across multiple gestational ages were conducted in Simcyp to evaluate the potential changes in lacosamide pharmacokinetics during pregnancy. Additional simulations were performed to explore the effects of cytochrome polymorphisms and glomerular filtration rate variability.

RESULTS

The model adequately described the evaluation data in nonpregnant adults and pregnant adults between 10 and 40 weeks of gestation. Estimates in patients at 40- weeks of gestation indicated that lacosamide clearance increased by 48.2% compared to nonpregnant patients. Maximum lacosamide concentration (Cmax) during a simulated dosing interval also fell by 30% from preconception to 40 weeks. A simulated dose increase of 50 mg once daily at 10 weeks of gestation supported maintenance of preconception concentration for a typical patient taking the most common dosing regimen of 200 mg, twice daily (BID), preconception.

SIGNIFICANCE

Simulated changes in lacosamide concentration align with the limited data available in observational studies. Our simulations support the use of therapeutic drug monitoring and dose adjustments to maintain the efficacy of lacosamide pharmacotherapy.

Investigation of spontaneous abortion and stillbirth adverse events in epilepsy patients treated with levetiracetam: A pharmacovigilance study

BACKGROUND

The prescription of levetiracetam during pregnancy has become more common due to its lower teratogenic risk profile. However, due to a lack of data about its association with stillbirth and spontaneous abortion, worries remain.

OBJECTIVE

To investigate information on any possible association of spontaneous abortion and stillbirth adverse events with levetiracetam in women with epilepsy.

METHODS

This retrospective pharmacovigilance study used disproportionality analysis to detect signals of adverse reaction of interest reported with Levetiracetam in FAERS, the FDA Adverse Event Reporting System. The ratio of reporting odds (ROR) and information component (IC) indices were used to undertake disproportionality analyses, and change point analyses were carried out to identify variations in the frequency of reporting of relevant adverse events. Sensitivity analyses included subgroup analyses by indication, treatment regimen, and reporting region.

RESULTS

Overall, 2870 cases of spontaneous abortion and stillbirth with commonly used antiseizure medications were analyzed. A total of 65.5 % of these cases had epilepsy as the indication. In the entire dataset, we observed disproportionality signals of spontaneous abortion for 6 ASMs (levetiracetam, carbamazepine, lamotrigine, oxcarbazepine, topiramate, valproic acid) and disproportionality signals of stillbirth for 4 ASMs (levetiracetam, carbamazepine, lamotrigine, oxcarbazepine). In the epileptic population, disproportionality signals for stillbirth (ROR0.25 = 4.60; IC0.25 = 1.30) and spontaneous abortion (ROR0.25 = 3.98; IC0.25 = 1.20) in levetiracetam was identified. These disproportionality signals have been consistently robust over the past years, according to a temporal assessment of them. Sensitivity studies proved how reliable the findings were.

CONCLUSION

Using validated pharmacovigilance methods, we found significant disproportional signals for spontaneous abortion and stillbirth associated with levetiracetam. Of these, the signals for spontaneous abortion were observed after 2011 and for stillbirth after 2014, which may be related to the rise in levetiracetam prescriptions during pregnancy in recent years. The association of spontaneous abortion and stillbirth adverse events with levetiracetam and potential biases confounding this association merit further investigation.

The impact of pregnancy-related hormonal and physiological changes on antiseizure medications: expert perspective

INTRODUCTION

Epilepsy is a disorder of recurrent, unprovoked seizures affecting approximately 15 million individuals of childbearing potential worldwide. Patients with epilepsy rely on regular daily therapy with antiseizure medications (ASMs). Furthermore, ASMs are also prescribed for other neuropsychiatric indications (e.g. bipolar disorder, pain, migraines) with over 2% of the pregnancies in the United States involving prenatal exposure to ASMs.

AREAS COVERED

ASM concentrations are affected by hormonal and physiological changes in pregnancy, including increases in renal and hepatic blood flow, decreased protein binding, and changes in enzyme activity. Clearance changes typically reverse within a few weeks after delivery. During pregnancy, many ASMs, such as lamotrigine, levetiracetam, and oxcarbazepine, should have serum concentrations monitored and doses increased to maintain the individualized target range for seizure control. ASMs metabolized via glucuronidation, primarily lamotrigine, undergo marked increases in clearance throughout pregnancy, requiring about 3-fold the pre-pregnancy daily dose by delivery. Postpartum, ASM doses are usually decreased over several weeks to prevent drug toxicity.

EXPERT OPINION

In the future, the development of a physiologically-based pharmacokinetic model for various ASMs may enable empiric dose adjustments in pregnancy without the difficulties of frequent therapeutic drug monitoring.

Epilepsy and education: A case-control analysis of the impact of an intensive epilepsy training program on undergraduate medical students

AIMS

To evaluate the knowledge, attitudes, and practical skills of students submitted to a 6-week intensive training in epilepsy compared to students without any training but mandatory neurology classes.

METHODS

It is a case-control study. After completing a 6-week intensive Academic, Clinical, and Research Program in epilepsy, TUMSs answered a validated Knowledge Attitudes and Practices (KAP) questionnaire. The control group, composed of undergraduate students who shared the same age, academic year, and compulsory hours for learning about epilepsy as TUMSs, was also assessed through the KAP instrument. Answers from both groups were submitted to Fisher exact and the χ2 test to observe differences among groups. Descriptive statistics were also performed.

RESULTS

TUMSs displayed better results in theoretical knowledge such as the definition and causes of epilepsy, and the application of paraclinical studies essential for diagnosing epilepsy. From their perspective, people with epilepsy encounter restricted opportunities for preserving their social life and employment and they are more prone to workplace accidents. They are convinced that facing epilepsy presents a notable risk due to the difficulties linked with diagnosis, considering epilepsy a challenging disease for general practitioners to identify and follow up. Likewise, they exhibited improvement in treatment adjustment and treatment monitoring of patients with epilepsy, mainly in pregnancy cases. Finally, they had greater knowledge about what to do when they witness a person experiencing a seizure.

CONCLUSION

Our study showed that a 6-week intensive education program in epilepsy increased the knowledge and practical skills and changed the attitude toward patients with epilepsy of undergraduate students.

Effects of valproic acid on syncytialization in human placental trophoblast cell lines

The placenta is a critical organ for fetal development and a healthy pregnancy, and has multifaceted functions (e.g., substance exchange and hormone secretion). Syncytialization of trophoblasts is important for maintaining placental functions. Epilepsy is one of the most common neurological conditions worldwide. Therefore, this study aimed to reveal the influence of antiepileptic drugs, including valproic acid (VPA), carbamazepine, lamotrigine, gabapentin, levetiracetam, topiramate, lacosamide, and clobazam, at clinically relevant concentrations on syncytialization using in vitro models of trophoblasts. To induce differentiation into syncytiotrophoblast-like cells, BeWo cells were treated with forskolin. Exposure to VPA was found to dose-dependently influence syncytialization-associated genes (ERVW-1, ERVFRD-1, GJA1, CGB, CSH, SLC1A5, and ABCC4) in differentiated BeWo cells. Herein, the biomarkers between differentiated BeWo cells and the human trophoblast stem model (TSCT) were compared. In particular, MFSD2A levels were low in BeWo cells but abundant in TSCT cells. VPA exposure affected the expression of ERVW-1, ERVFRD-1, GJA1, CSH, MFSD2A, and ABCC4 in differentiated cells (ST-TSCT). Furthermore, VPA exposure attenuated BeWo and TSCT cell fusion. Finally, the relationships between neonatal/placental parameters and the expression of syncytialization markers in human term placentas were analyzed. MFSD2A expression was positively correlated with neonatal body weight, head circumference, chest circumference, and placental weight. Our findings have important implications for better understanding the mechanisms of toxicity of antiepileptic drugs and predicting the risks to placental and fetal development.

Present in the Aquatic Environment, Unclear Evidence in Top Predators-The Unknown Effects of Anti-Seizure Medication on Eurasian Otters (Lutra lutra) from Northern Germany

Emerging contaminants are produced globally at high rates and often ultimately find their way into the aquatic environment. These include substances contained in anti-seizure medication (ASM), which are currently appearing in surface waters at increasing concentrations in Germany. Unintentional and sublethal, chronic exposure to pharmaceuticals such as ASMs has unknown consequences for aquatic wildlife. Adverse effects of ASMs on the brain development are documented in mammals. Top predators such as Eurasian otters (Lutra lutra) are susceptible to the bioaccumulation of environmental pollutants. Still little is known about the health status of the otter population in Germany, while the detection of various pollutants in otter tissue samples has highlighted their role as an indicator species. To investigate potential contamination with pharmaceuticals, Eurasian otter brain samples were screened for selected ASMs via high-performance liquid chromatography and mass spectrometry. Via histology, brain sections were analyzed for the presence of potential associated neuropathological changes. In addition to 20 wild otters that were found dead, a control group of 5 deceased otters in human care was studied. Even though none of the targeted ASMs were detected in the otters, unidentified substances in many otter brains were measured. No obvious pathology was observed histologically, although the sample quality limited the investigations.